306005390-6-9-2020-22-AS-LADS-BQHSTC-20200612140920

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005390
Report Date: 06/09/2020
Date Signed: 06/09/2020 01:44:37 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/23/2020 and conducted by Evaluator Patricia Velazquez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20200323112054

FACILITY NAME:	AFFINITY HOME CARE		FACILITY NUMBER:	306005390
ADMINISTRATOR:	GUTIERREZ, CECILIA		FACILITY TYPE:	740
ADDRESS:	7101 NIMROD DRIVE		TELEPHONE:	(562) 676-5369
CITY:	HUNTINGTON BEACH	STATE: CA	ZIP CODE:	92647
CAPACITY:	6	CENSUS: 6	DATE:	06/09/2020
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Heather Edgington - Administrator		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Staff shared confidential information
Staff did not allow visitation

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Patricia Velazquez contacted the facility via telephone to conduct a subsequent complaint investigation visit utilizing FaceTime virtual technology due to the COVID-19 Pandemic and pre-cautionary measures. LPA Velazquez identified herself and discussed the purpose of the call. LPA spoke with Administrator Heather Edgington and discussed the above allegations.

On today's visit LPA Velazquez conducted a virtual tour of a portion of the physical plant along with Administrator Edgington and briefly spoke with Resident (R) #1 who was resting in their room. LPA also conducted an interview with Administrator Edgington. LPA then requested additional hospice records for R1.

During the course of the investigation the following was revealed: LPA Velazquez reviewed documents in R1's file such as the Physician's Report, Resident Appraisal, PrePlacement Appraisal, Functional Capabilities Assessment, Admissions Agreement and Memorial Care Hospice records. LPA reviewed a facility letter to

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (714) 380-0440
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20200323112054

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: AFFINITY HOME CARE	FACILITY NUMBER: 306005390
	VISIT DATE: 06/09/2020

NARRATIVE

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residents' family members dated March 15, 2020 regarding visitor restrictions due to the Coronavirus/COVID-19 Pandemic. LPA also reviewed text and email communication between the Complainant and Administrator Edgington. LPA also interviewed Administrator Edgington regarding Staff (S) #3's involvement with the facility as well as the complainant via email and LPA was provided conflicting statements. S3 was present in the facility during the initial meeting with R1's family where the family shared confidential information in the presence of S3. Based on the aforementioned evidence the above allegations could not be corroborated.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations that Staff shared confidential information and Staff did not allow visitation are both deemed UNSUBSTANTIATED.

An exit phone interview was conducted with Administrator Heather Edgington and a copy of this report was signed by LPA Patricia Velazquez. A copy of this report along with the appeal rights and LIC 811s were provided to Administrator Heather Edgington via email. This report will be sent via email to Administrator Heather Edgington who agrees to sign and date the report. This report was sent via email and an electronic read receipt confirms receiving the report. Administrator Heather Edgington agrees to send the original signed report by mail to the CCLD Regional Office in Orange.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (714) 380-0440
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2020

LIC9099 (FAS) - (06/04)

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